Impact of Case Payment on Physicians Practicing Vaginal Birth after Cesarean Section

　　目標：本論文旨在探討中央健康保險局推出「前胎剖腹產之陰道生產」（Vaginal Birth after Cesarean Section, VBAC）論病例計酬，在控制醫療、醫師及產婦因素後，對醫師執行剖腹產後自然產的醫療行為之影響。方法：本研究係以某財團法人醫療體系四家分院的30位婦產科醫師，及所照護的2,246位曾有過剖腹產經驗的產婦為研究對象。研究人員利用該醫療體系的次級資料，並以配對t檢定（paired t-test）及邏輯斯蒂迴歸分析（logistic regression analysis），予以檢定VBAC論病例計酬此財務誘因，對醫師執行VBAC此醫療行為的影響力。結果：配對t檢定結果顯示，在VBAC論病例計酬實施後的研究期間，樣本醫師執行VBAC的比率較實施前的研究期間增加6.06%（p＜0.001）。而邏輯斯蒂迴歸分析結果則顯示，除了VBAC論病例計酬實施此自變項外，產婦主要臨床診斷及產婦年齡等控制變項，對醫師是否執行VBAC亦具有顯著性的影響力。結論：本論文的研究結果顯示，VBAC論病例計酬實施後樣本醫師執行VBAC的比率有增加的現象；換言之，外部支付制度在某種層面上對醫師之醫療行為確實具有影響力。
　　Objectives: To reduce the cesarean delivery rate, Taiwan’s Bureau of National Health Insurance (BNHI) introduced the “Vaginal Birth after Cesarean Section” (VBAC) case payment program on April 1, 2003. The purpose of the current study was to determine the impact of case payment on physicians practicing VBAC. Methods: The data used in the study were derived from the health care system in Taiwan, including four of the system’s hospitals, 30 obstetric attendings, and 2,246 gravidas with a previous cesarean section delivery under the attending physician’s care. A paired t-test was used to analyze the VBAC rate before and after the introduction of the VBAC case payment initiative. Logistic regression analysis was then performed to determine the relationship between VBAC case payment and the likelihood of physicians practicing VBAC, controlling for related variables, such as previous cesarean section delivery of the sample gravidas. Results: After implementation of VBAC case payments, the VBAC rates at the sampled hospitals increased 6.06% (p<0.001). Logistic regression analysis showed that implementation of VBAC case payments and major clinical diagnoses were significant predictors of physicians practicing VBAC. Conclusions: The results of the current study indicate that after implementation of the VBAC case payment initiative, physicians demonstrated an increased tendency to offer VBAC. Thus, financial incentives exert an impact on a physician’s practice behavior.